Women and depression. Why are they twice as often depressed as men?

women depression

If this statistic is true we first need to establish those factors causing depression

before then examining whether and why women are more exposed to those factors than men, less resilient in the face of these factors or, perhaps, both.

Given this approach it is a pity that there is no consensus within the psychotherapeutic community (or outside of it) as to the aetiology of the depressive disorders.

Is depression a result of a serotonin imbalance

The biomedical model, for example, sees depression as possibly being the consequence of an imbalance of serotonin within the brain which may or may not, in women, be complicated by hormonal cycles pertinent to menses or changes occurring as a result of menopause. Freeman and Freeman (2013) note that males and females experience similar rates of depression until the onset of menses. The Karolinska Institutet (2008) reports that women have different systems (including fewer receptors) for the management of serotonin and that this difference may account for their higher rates of depression and anxiety. The same study also found that serotonin was less efficiently managed in those women who reported serious premenstrual “mental” (sic) symptoms. Could this be the sole answer, that women are victims of neurobiology and their reproductive system’s cyclical impact upon their hormonal states?

(I do see lots of women who need help with regard to menopause or PMT. If you’d like some help then click here to contact me)

Sheline (1999) suggests that it may not be so simple. Sheline found that the hippocampus shrinks in people who suffer persistent stress and anxiety (Freeman and Freeman (2013) suggest that this may be caused by excessive amounts of cortisol). Sheline suggests (1999) that the changes to the hippocampus may damage serotonin receptors within that part of the brain. Could it be, therefore, that having a lower base level of serotonin receptors does not rob women of the ability to manage serotonin efficiently but that anxiety and stress do lead to a reduction in their numbers, rendering women more prone to depression? If this were to be the case, would it not be better to resolve anxiety and stress than focusing merely on symptomatic difficulties with serotonin? As Gerhardt (2004) shows, our cultural and inter-personal environment has an effect upon neurological development. Furthermore, as Doidge (2008) argues, the brain remains ever plastic and what is done can be undone. We are not helplessly subject to our brains but build and adapt them throughout the life-course. Our primary care-givers may have helped to make our brains what they are (Gerhardt 2004) but we have the power to change them. The cause of depression in women, therefore, lies further along a chain of causation than a shortage of serotonin. Depression in women is  more than their simply being casualties of evolution.

These discussions surrounding biology and environment become circular. Even the Karolinska Institutet (2008) is not yet ready to declare that their findings present an answer to this ongoing chicken and egg style debate:  “We don’t know, yet, what this means.”

Perhaps it’s genetic…

depression and genes

Freeman and Freeman (2013) suggest, using studies of identical twins, that genetics may predispose people to depression. Furthermore, studies cited within the same text suggest that it is “likely” (p95) that depression is more hereditable in women than in men. However, they assert that genes only become expressed when working in tandem with environment and separating one from the other is notoriously difficult. After all, there are plenty of people who have depressed parents and yet do not go on to suffer the condition themselves. So, the biomedical model would appear to have merit and yet does not provide the whole explanation. If genes predispose some people to depression we still have to answer the question of what it is which causes their expression. We also need to discover what it is which causes depression in those people with no genetic predisposition. Freeman and Freeman (2013) conclude (p105) that “what happens in the brain – fascinating though it undoubtedly is – is just the biological effect of … stressful events.”

Are they right? If so, how do these stressful events cause depression and are women more likely to experience them?

Seligman (1975) wrote before the biomedical model of depression reached its present level of maturity. He stated that depression is a state of learned helplessness as a result of stressors which the sufferer believes to be insurmountable. Potentially traumatic events thus constitute a form of conditioning. In this his work is akin to that of Skinner but he later revised his thoughts (1998) and thus drew closer to Beck (1985) and the cognitive model of depression in concluding that it was the sufferer’s “attributional style” which led to learned helplessness. In other words, it is as Epictetus wrote: that our responses to events cause us unhappiness rather than events in themselves.

Depression, in the eyes of Beck, is little more than a “thinking disorder” (McGrath & Keita et al 1990: 57).

As Beck suggests (1985), it is through adapting our cognitive schema that we can resolve depression. Seligman agrees (1998). We can learn optimism and rid ourselves of maladaptive responses to negative events. Is it possible, therefore, that women are simply more prone to a “thinking disorder” than men, that women are inherently more prone to a pessimistic outlook on both life and their ability to cope with its vicissitudes? Are women more vulnerable to learned helplessness?

If this is so then one might reasonably ask what led to the “thinking disorder” in the first place.

(I personally believe that it’s our emotions which cause us to warp our thinking. If you’d like some help with any emotional problems then find out a little more about Resolved! Hypnotherapy by clicking here)

Psychodynamic theory offers an answer. Psychodynamic therapists opine that neuroses (of which depression is one) originate in a disturbance in the child’s developmental stages (Brown and Pedder 1979). The attachment theorist Howe (2011) might not attach the same emphasis to concepts such as the oedipal complex, ego, super-ego and id but he would agree that the disturbance in the child’s relationship with a caregiver renders him or her less able to form secure attachments in the future. It is this inability to form relationships which he feels is responsible for mental health risks such as depression. This has given rise to an entire relational model of depression through which depression is seen as being the result of a disturbance in the sufferer’s relationships with others around them. Are women more vulnerable to such disturbances?

Gerhardt (2004) turns attachment theory, looking at infancy, back to the biomedical model

attachment theory

She demonstrates how the developing brain is affected by an excess of cortisol when subject to an unhealthy relationship with primary care-givers. The brain’s development is negatively affected and thus the ability to form healthy attachments in later life is impeded. This, she believes, is a risk factor for depression. Her view is supported by Freeman and Freeman (2013) who show that the hypothalamic pituitary adrenal axis (which governs our response to stressful situations) can be changed indefinitely by childhood stressors.

It is not difficult to imagine that these problems in childhood and subsequent difficulties in forming relationships in adult life could contribute to the maladaptive schema which Beck, Rush et al (1979) feel to be to blame for depression. Neither is this incompatible with the belief of gestalt therapists that the inability of a sufferer of childhood attachment disturbance (or a psychodynamic disturbance in their developmental stages) to reach closure – to reach closure in the disturbance of their awareness cycle – is at the root of their depression (Clarkson 2004). Indeed, psychodynamic and gestalt therapists would agree that a child in such a position would be prone to “toxic” introjections and that these would be dealt with through repression.  Freud would not disagree with Perls (1951) when he states (p216) that the “seeming lethargy” of depression is a mere “holding in check” of strong repressed emotions.

Neither is it such a difficult leap of faith for such writers to imagine that those suffering such lethargy would find themselves facing an existential crisis.

existentialism (2)

Logotherapy, according to Cooper (2003) would see the depressed individual as lacking a sense of any meaning to life. Indeed, healing and recovery would depend on finding such a meaning. Van Deurzen (2012) agrees, adding that the depressed individual would “opt out of life” (p50) – ignoring (repressing) his or her feelings and “admitting defeat.” This is not so far away from Beck (1985) and his belief in maladaptive schema. Neither is it a million miles from Seligman (1975) and learned helplessness.

This is but a limited sample of the various theories as to the aetiology of depression. There is no room in this essay for a thorough exploration of any of them and none of them will confess to being but a small part of the answer. It is patently possible, however, that all of them have some validity. One could go so far as to claim that the various schools of therapeutic thought are merely engaged in looking at various parts of the same elephant. It would seem as if they all cling to their respective parts and swear that their trunk, ear, tail or tusk represent the whole.

It would, therefore, seem entirely possible that one could synchretise them all into a viable theory of depression. One could quite easily argue that depression occurs when a major negative event, or a chain of such events (which may or may not extend back into childhood and with which the subject feels powerless to complete a gestalt), causes a person whose attributional style may or may not be negative (and who may or may not have a genetic predisposition) to feel as if they are no longer able to cope. A state of lethargy, a sense of meaninglessness and / or learned helplessness, thus ensues from which the sufferer feels unable to escape.

This would be a rather broad and open theory of depression and such an integrative and permissive model would fall reasonably neatly into the broad humanistic camp. Depression would be a phenomenological experience and the therapist would look to meet the client on his or her own ground. Depression would be that which the client reports it to be and although the therapist may or may not find it useful to help the client understand how they arrived where they are, the client would be left as the expert on the subject of their own self (Rogers 1961).

(My clients are the experts on what’s wrong, even if they don’t know it yet. If you’d like a little help with depression or anxiety then please click here to find my contact details)

In seeking to determine the causes of depression we have thus far established that they do not fall neatly into the structures of any one particular school of thought.

The depressed client may have suffered negative life events which now appear overwhelming, they may have relational problems which possibly stem from attachment issues, they may well suffer maladaptive cognitions, they may have neurological contributors in play and they may feel as if life has neither sense nor purpose. One or more of these may be present. One, several, many may not.

The question remains, however, how one person falls victim to depression whilst another who experiences similarly negative conditions does not.

Unless we find that the biomedical model fully explains the incidence of depression the answer must lie within the individual’s psyche. It becomes, therefore, a question of emotional resilience.

The Emotional Resilience Steering Group (2009) describes emotional resilience as being “A set of conditions that allow (sic) individual adaptation to different forms of adversity at different points in the life course.” Others, however, claim that it is more than a mere set of qualities. “Emotional Resilience is not a state of mind but a way of life. We all want and need it in order to face life unencumbered by unrealistic fears and be able to communicate freely with the people we love most” Viscott (1996). Havens and Walters (2002) explain that we, as humans, all seek emotional comfort and instinctively seek to avoid emotional “discomfort.” We not only desire emotional resilience but are driven at our very core to establish this ability, this cognitive and emotional process. Rogers (1961) would term this a part of the self-actualisation process.

Viscott (1996) explains that emotional resilience helps people to tell the truth, face life openly, accept themselves for who they are, accept others for that which they are, take responsibility for their own lives, cease trying to prove themselves, let go of the past, know and accept their weaknesses and say what they mean, feel and believe.

It is, in short, the means by which we maintain a healthy emotional state despite the “slings and arrows” which Shakespeare writes are thrown our way. It is impossible to imagine a fully emotionally secure human being who does not possess these attributes.

Whey then, assuming the statistics to be correct, are women less emotionally resilient in the face of those factors which cause depression?

women anger

Are they lacking in something or is it the case that women face pressures upon resilience which men do not?

Lois Frankel (1991: 20) believes that she has the answer. She sees women facing a “choice… to succumb to the wishes of others or to live a life of constant battle. For many the answer lies in depression.” Women are more likely to be expected to assume certain roles in life (mother, wife, care-giver) and these pressures force them to attend to the needs of others whilst neglecting their own. The individual and personal dreams and ambitions of women are thus less likely to be fulfilled leading to an anger which is turned inwards. McGrath and Keita et al (1991) tentatively agree that this may be a factor, that a sense of not being in control of one’s life may lead to a sense of learned helplessness or hopelessness when the woman is “not…able…to attain highly valued outcomes or to avoid aversive outcomes.”

There is certainly a great deal of literature which suggests that women are the victims of an imbalance of power and opportunity between the genders.

This leaves them less able to achieve their own personal goals. Rosaldo (1974) believes that this imbalance originates in female biology and is exhibited in the division between the domestic and public spheres of life, a division which sees women predominantly tied to their biological domestic roles as mothers and the associated role of caring for others around them. Power and status become a male preserve and domestic roles are devalued. Imray and Middleton (1983) argue that the consequent devaluation of women extends into the public sphere, that women are seen as being of a lesser value even when they take paid employment outside of the home.

Engels (1972) might agree with this division but focuses primarily on its sexual and economic origins. According to Engels (1972) men gained the whip hand over women when settled agriculture gave them complete control over the division of more abundant resources. They used this control to restrict the formerly polyamorous instincts of women. Women thus became property.

Neither of these theories exists unchallenged and yet every sociological theory of sex and gender holds that women have held less power than men and that these imbalances remain to this day. McGrath and Keita et al (1991) would thus conclude that being female is a risk factor for depression since women are therefore relatively unable “to attain highly valued outcomes or to avoid aversive outcomes.” It is for this reason that many feminist writers would reject the biomedical model. Chesler (2005) complains that women have been seen as “hysterics … and driven to excess by their hormones.”Chesler, instead, cites Pipher (1994) who believes that the West has a “girl poisoning” culture which places impossible demands on women. Girls become “female impersonators” and suffer as a result, chiming with Rogers’ belief (1961) that living incongruently is a foundation of unhappiness. Freeman and Freeman (2013) would possibly agree that living in such a culture would explain what then happens to the brains of women.

Do women really still suffer from a deficit in power at a time when legislation exists to protect and advance them? One could consider that the existence of such legislation proves the problem. What does the evidence suggest?

The most recent UK census (2011) shows that women are more likely to be economically inactive than men. Those who work are three times more likely to be in part time work than men, leading to an inequality in average income and a generally lower status than female peers who work full time and men who do the same. This over-representation in part time jobs is largely accounted for by the adoption, by women, of traditional caring roles within the family and would seem to have an impact on depression, since non-employed wives (with no marital strain) are twice as likely to experience depression than employed wives with no marital strain (Aneshensel 1886). Furthermore, despite a recent “feminisation” of the workplace women workers remain concentrated in jobs and roles which remain “underpaid and undervalued” (Guardian 2013). McGrath and Keita et al (1990) report that occupational prestige and status are important predictors of mental health for both men and women. Women are thus more prone to mental dis-ease if they find themselves confined to a lower occupational status than they feel they merit and deserve. On the other hand, a recent survey (Telegraph 2013) found that six in ten mothers would wish to go part time, to spend more time with their children, if they could afford it. This form of stress may also contribute to depression where mothers cannot leave work to fulfil their family based desires. Different women feel pulled in different directions but the different stresses may prove to be of equal toxicity to emotional well-being.

(Many of my female clients experience problems balancing their different roles. I’d be happy to help you to find a new sense of poise. Feel free to contact me here)

However, McGrath and Keita et al (1990) state that this cannot be the only answer since many women who find themselves working either more or less than they’d like do not succumb to depression. The answer, perhaps, lies with Abrahamson et al (1978) who discovered that attribution style also plays a contributory part in the process by which women in traditional roles succumb to depression. Freeman and Freeman (2013) certainly find that women are more likely to engage in a ruminative style of thinking and are thus more likely to have a negative attribution style. However they and Abrahamson et al (1978) found this was only a risk factor for depression when negative life events were also present. It seems, therefore, that women who accept and perhaps enjoy their role may be less likely to experience depression and that the balance of work and domestic conditions thus pose no intrinsic dangers to mental health. Are we back to Epictetus – that it is merely our interpretation of a negative event or circumstance (attributional style) which causes us distress?

It would certainly appear possible and yet it is far from being the sole potential cause. As Bonnano, Galea et al (2007) demonstrate, the existence of pre-existing life stresses can predispose towards trauma. One may be resilient in the face of a series of stressful situations only to find that one further potentially traumatising event tips the individual into depression. Job’s Biblical misfortunes are recorded because of his exceptional emotional resilience. The vast majority of people, no matter how resilient they have previously proven to be, will eventually crumble under too great a series of mishaps (Viscott 1996). A negative attributional style may be a contributory factor but the evidence suggests that even those who counted themselves among life’s optimists and who are free of genetic vulnerability may suffer depression if the load of potentially traumatising events proves too great.

So perhaps it is simply the case that women are exposed to potentially traumatising events more frequently than men.

This would seem to be the case. Freeman and Freeman (2013) observe that girl are ten times more likely to experience childhood sexual abuse than boys. The US Department of Justice (2013) states that 85% of victims of domestic violence are women. Furthermore, 25% of women suffer such violence. One in five women over 16 years of age experience some form of sexual violence (Rapecrisis 2013). Twice as many women as men (workharassment.net 2010) reported having been a victim of sexual harassment at work. Women, of course, also bear the brunt of issues such as infertility, unwanted pregnancies, miscarriages and abortions.

Furthermore, the list of potentially traumatising events does not diminish with age. Men may experience as many health problems as women as they age but women are statistically more likely to experience the death of a spouse (given average life spans) than men. Knight (1996) does explore the view that depression after such a loss is dependent on emotional resilience prior to this loss but the fact remains that women are more likely than men to be exposed to such a stressor. Knight (1996) also explains that widowers are more likely to remarry in old age than are widows. Given the ratio of male to females living to extreme old age this is inevitable. However, the lack of eligible men in their 70s onwards is of little comfort to the widow left alone and possibly living for decades beyond the death of her partner. Her children may, by now, be living far away with families of their own to tend and her own frailty may mitigate against the maintenance of protective social networks.  The list of potentially traumatic events which affect women more frequently than men goes on and on.

Furthermore, adverse circumstances can be as wearing as distinct events (Freeman and Freeman 2013). McGrath and Keita (1990) find that women experience less of a protective effect than men when happily married and experience much higher rates of depression where they find themselves unhappily married, rates which are higher than for men who are similarly unhappy in their marriages. This would appear to be the case even when unhappy marriages do not feature violence or abuse of any kind. Perhaps this is partly down to Howe’s (2011) observation that those who experience insecure attachment as children are more likely to find unsatisfactory relationships as adults. Women are perhaps more likely to suffer this process since they are more likely to experience potentially traumatic events as children.

The quality of a woman’s relationships thus seems to be an important indicator of depression.

relationships women

Viscott (1996) stresses the importance of a supportive social network in maintaining emotional resilience and yet Freeman and Freeman (2013) argue that larger social networks only increase the risks of stress through negative events which happen to loved ones. McGrath and Keita (1990) agree, stating that women suffer greater levels of “vicarious” stress through having a wider “range of caring” than men. A larger social network, therefore, is a double-edged sword for women.

(Relationship problems? Let me help you. Learn more about how Resolved Hypnotherapy works by clicking here)

Freeman and Freeman (2013) observe that women tend to have more ruminative thinking styles than men.

This may assist women in learning how to navigate complex social situations, (as Freeman and Freeman (2013) observe, female children as young as two display more socially orientated behaviours than males) but it will often prove deleterious when ruminations turn thoughts to questions of self-blame and guilt. Neither will this prove helpful when women turn to considering and ruminating upon any events in childhood or later life which proved traumatic. Rumination when combined with a statistically greater chance of experiencing certain types of traumatic event and a greater emphasis on social relationships (which attachment theory (Howe 2011) holds will prove more difficult when traumatic events cause insecure and/or avoidant attachment patterns) would seem to be fertile ground for depression.

Furthermore, puberty and the onset of menses bring yet more problems for the developing female – problems which are not held to have an equivalent in males.

Phillips (1986) cited research which showed that 93% of women worked to improve upon their appearance, a greater percentage than that of men. Russell (1995) links this pre-occupation to eating disorders and other emotional disorders in women. Women are programmed to seek slenderness just as the onset of puberty works in the other direction. Freeman and Freeman (2013) agree, arguing that women are victims of a cultural bias towards a body shape which is pre-pubescent and impossible to maintain. This may be yet another factor which increases the statistical likelihood of women experiencing depression more frequently than men. After all, puberty brings men just that body shape which is most prized.

None of this is to suggest that men do not experience stressors or depression.

Untitled design (8)

After all, men do suffer sexual abuse, rape, relational isolation and other potentially traumatic events as well.\men are also as prone to measure themselves against an unattained physical ideal and have the added pressure of concerns regarding sexual performance, virility and the size of their penises. Nonetheless, Freeman and Freeman (2013), McGrath and Keita (1980) and others assert that men are more in control of their own selves. They are more likely to be economically independent, of a higher socio-economic status, freer from domestic chores, less ruminative and less vulnerable to hormonal cycles than are women. They may, on average, enjoy smaller social networks but these thus pose less of a risk of “vicarious” grief.” Moreover, men are considered (Freeman and Freeman (2013)) to be more responsive to stress in that they adopt therapeutic hobbies outside of the home such as gym membership, fishing or other physical activities. This may be a result of a greater independence from domestic responsibilities but whatever it may be, men do seem more able to avoid depression than women.

Men are (Harvard Health Letters 2010) twice as likely to suffer substance abuse as women.

It is beyond the scope of this essay to delve too far into the statistics but it would appear that men suffer stress differently than women and respond differently also. There is also the question of whether women are more likely to report depressive symptoms than are men. The Mental Health Foundation (2014) agrees, citing that women are twice as likely as men to report depressive symptoms but that this may not represent the whole picture. Men may simply refuse to report such symptoms due to a cultural bias against male weakness whilst being happier to report substance abuse. The same authors report that 80% of those presenting to GPs for alcohol dependency are men. Whether reporting this dependency means that depression is addressed (through whatever interventions are then put in place by medical care providers) without being identified is unclear. What is clear, however, is that the naked statistic of women being twice as likely to suffer from depression as are men is not an entirely clear cut matter.

Nonetheless, women do report depression twice as often as men and this would appear to be due to a combination of reasons which feed off one another. Science and psychotherapeutic theory may offer insights into why this may be the case but it is a testament to the infinite complexity of the human experience that we may never be able to separate quite how biology, genetics, relationships, attributional style, potentially traumatic experiences, learned helplessness, socio-cultural factors and emotional resilience contribute to the appearance of depression in one individual and its absence in another. What is left to us is the need to listen to the client before us without attempting to shoehorn her into any one theoretical straightjacket. As Rogers (1961) states, the client has all the answers if we are sufficiently open minded to ask the right questions.

 

Reference List.

 

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